Traumatic Abdominal Hernias: When to Operate

An 82-year-old man presented to the ED with abdominal pain. While
walking in his yard he had fallen onto a two-inch-diameter piece of
steel rebar. EMS reported seeing a locally expanding area while the
patient was being prepared for transport. He had no history of surgery
or swelling in the affected region.

On examination the patient was normotensive without signs of shock. He
had a small abrasion on his head but did not lose consciousness, showed
no altered mental status, and did not have a headache or focal
neurological signs. His abdomen revealed a well-circumscribed area where
the rebar impacted, with an abrasion extending inferiorly. His abdomen
was soft, tender only over the abrasion, with no rebound or guarding or
abnormal bowel sounds. There were no other positive exam findings.

Labwork, including CBC and creatinine, was normal. An abdominal CT with
contrast showed a left lateral abdominal wall hernia. The hernia had a
four-centimeter neck and contained colon without findings of
obstruction, perforation, or significant hematoma.
The patient was referred to the trauma service and underwent an urgent
abdominal exploration and repair of the traumatic hernia. A small
serosal hematoma was discovered on the descending colon, which was
unroofed and then repaired after showing no evidence of a full thickness
injury. The hernia was reduced and the abdominal wall defect was
repaired without mesh.

The patient developed a post-operative ileus and paroxysmal atrial
fibrillation but was discharged home in stable condition twelve days
later.